Stories From the Field:

INDIA

Anemia and adolescent health in India

Nupur Gupta, MD, MPH, Pediatrician at Mass General Hospital for Children (MGHfC) was granted a Center for Global Health Travel Award to conduct research on anemia in India.

I visited India in April-May 2013 to assess research possibilities for the use of non-invasive technology to screen for anemia in adolescent and young adult populations in Udaipur, Rajasthan and Nagpur, Maharashtra, using the Pronto-7 device. This is a pulse oximeter which is FDA approved for spot hemoglobin measurements.  I was intrigued by the gender differentials noted on the National Health and Family Survey (Indian equivalent of the Demographic and Health Survey) in hemoglobin levels in adolescent and young adult populations.  I also wanted to collaborate with medical providers in Udaipur and Nagpur to create research and teaching opportunities in adolescent global health and consider the creation of an educational elective site for MGHfC pediatric residents who are interested in global health.

My trip started in Udaipur, Rajasthan.  I chose to collaborate with a non-profit organization, Seva Mandir, which is the largest non-profit in Rajasthan serving about 600 villages around the city of Udaipur. I spent a day at the organization meeting with the health teams who have varied backgrounds including public health, social work, Ayurvedic Medicine and nursing. I demonstrated the use of the Pronto-7 device to the health workers and later to patients in the rural areas of Udaipur.  Several health care workers expressed interest in trying the device themselves to measure their own hemoglobin.  They liked the idea of screening adolescents, young adults and pregnant women for anemia using this simple device and we discussed how population screening could be done as anemia is a major health problem in rural Rajasthan with more than 60% of the population being affected. 

Seva Mandir also organized a trip so I could see Kojawada Hospital, a rural hospital in Udaipur district about 50 miles away from the city that was built with grant money they were awarded. Although initially doctors, nurses and some para-medical workers staffed the hospital, currently the only on-site medical staff there was a registered auxiliary nurse mid- wife and a part-time phlebotomist.

In 2012, Seva Mandir received a grant from the British Medical Association to provide free medical treatment (including evaluation, laboratory investigation and medicines) to all women and children.  As a result, the hospital is now able to conduct out-patient clinics three days per week. Hemoglobin estimations were currently being done with the use of a hemoglobinometer that utilizes colorimetric methods for assessment.  The majority of the patients were young women who were pregnant or wanting to get pregnant and more than 50% of them were anemic.

The second part of my trip involved travelling to Nagpur.  This is a city in Maharashtra state in the western part of the country and has a higher literacy rate, lower maternal mortality and overall better health indices than Rajasthan.   In Nagpur I was hosted by Dr. Archana Patel, the vice president of the Lata Medical Research Foundation.  I also visited the Indira Gandhi Medical College Hospital (IGMCH) and a Primary Health Center about 50 miles from Nagpur, bordering the tribal areas.   In Nagpur, as in Udaipur, medical professionals and para-professionals were very interested in non-invasive screening tools for evaluation of anemia. 

On the first day, Dr. Patel suggested that I take a tour of IGMCH before venturing out onto the villages.   I was fortunate enough to see the running of some of the clinics and meet some amazing and dedicated doctors.  Standing in front of the HIV Counseling Center I thought back to my practice of “confidential” HIV testing in my examination room at Mass General.  Here I sat amidst about a 100 women, young and old, some pregnant others not, some in burkhas with children on their laps all there for the same purpose, sitting down together to receive pre-test counseling for HIV. (HIV testing is free and now all medications are provided for free by the Government of India).

On my second day, I had the opportunity to conduct a field trip to a primary health center about 50 miles from Nagpur city, bordering on the tribal areas.  I was able to tour the facility and participate in a community meeting.  This had been organized so that I could meet the auxiliary nurse midwives, general nurse midwives, and the governments’ accredited social health activists who had come for this meeting from the sub-centers.  We discussed the possibility of training adolescents in responsible sexual behavior using small focus groups.  A number of those present had been trained to teach in small groups and felt that adolescents would welcome the opportunity to be able to discuss such issues, which are often taboo in the home setting. 

All in all, I am grateful to the Center for Global Health for providing me with travel support that allowed me to start collaborations with the wonderful organizations I visited.  Although I went with the purpose of starting projects to help non-invasively screen for anemia, it also gave me the opportunity to pursue my ideas to further adolescent health not just in a clinical, but also in a preventative way, around the world.